Dr. Lenze is Professor of Psychiatry, Washington University, St Louis, MO.
In the elderly, falls are a common and important problem. In the US, fall-related injuries cost approximately $30 billion per year, and about 30% of older adults fall at least once in a given year.1 One of the most feared consequences of falling is a hip fracture, which occurs in almost 400,000 older adults each year. Other consequences include other fractures, head injuries, and less serious injuries that can nonetheless impair function and quality of life.
Moreover, after a fall-related injury, many older adults can have a fear of falling, a common geriatric condition marked by anxiety and low self-confidence about walking safely. Although not a DSM diagnosis, fear of falling is recognized as a common source of functional impairment and distress (and increased risk of falls) in older adults.2
Falls are highly relevant to psychiatry because they are often preventable, and one of the most highly feasible prevention strategies concerns psychotropic drugs. Simply stated: if we reduce the use of psychotropic drugs that are known to cause falls (or better yet, avoid such drugs in the first place), we will greatly improve our older patients’ quality of life by preventing falls and fall-related injuries.
Case 1: Your patient is a 74-year-old woman who was referred to you by her primary care physician for management of a complicated psychotropic medication regimen. Her family is very concerned about her gait instability. Upon meeting her, you see obvious ataxia, and at times she has to hold on to the wall for support when she walks. She has had 3 falls in the past 6 months, one of which was serious enough to require a visit to the emergency department. Her family wants to know whether her medications increase her risk of falls—and what should be done about them.
How to reduce falls in older psychiatric patients
First, review your patient’s entire list of medications (not just the “psych” drugs) to look for any drugs that are known to cause falls, in order to stop them (or better yet, not to start them in the first place). There are 2 kinds of medication-related problems: the first are individual drugs that increase fall risk; the second are drug interactions that increase fall risk. For both of these, the most common drugs are sedatives, and in particular benzodiazepines. The Table lists commonly used medications in older adults that increase fall risk.
Be aware of the following clinical points about benzodiazepines and falls in older adults:
1 There are no “safe benzos”: all benzodiazepines have fall risk, including short-acting medications such as alprazolam.
2 There’s no therapeutic index for older adults: there is no dose at which benzodiazepines are effective for anxiety disorders yet safe from fall risk.
3 Sedation equals fall risk: a patient who complains of daytime sedation or shows signs of sedation on examination is a patient whose reaction time and postural control are reduced.
4 Risk is dose-related: the higher the dose, the greater the risk of falls. This can be an issue with the highly potent benzodiazepines such as clonazepam. A dosage of clonazepam 1 mg twice daily might not sound like a high dosage to many practitioners, but 1 mg of clonazepam is equal in potency to 2 mg of alprazolam or 4 mg of lorazepam.
Avoid the use of benzodiazepines, especially long-term use. Benzodiazepines initiated in a hospital or consultative setting (eg, the patient is anxious) should have an automatic stop in the order (eg, “stop prescription upon discharge”).
Do not prescribe benzodiazepines in the first place: many safer, effective treatments exist. Since the 2 main reasons for a benzodiazepine prescription are insomnia and anxiety, use behavioral methods as a first-line intervention. Cognitive behavioral therapy, brief behavioral therapy, and sleep hygiene are all good first-line choices for insomnia; cognitive behavioral therapy, relaxation training, and mindfulness training are all effective for chronic anxiety. In addition, both insomnia and anxiety disorders have effective medication regimens that are safer than benzodiazepines: trazodone, ramelteon, and melatonin for insomnia; and SSRIs, SNRIs, and mirtazapine for anxiety.
1. Centers for Disease Control and Prevention. Costs of Falls Among Older Adults. August 2016. https://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html. Accessed December 6, 2017.
2. Iaboni A, Flint AJ. The complex interplay of depression and falls in older adults: a clinical review. Am J Geriatr Psychiatry. 2013;21:484-492.
3. Joo JH, Lenze EJ, Mulsant BH, et al. Risk factors for falls during treatment of late-life depression. J Clin Psychiatry. 2002;63:936-941.
4. Gebara MA, Lipsey KL, Karp JF, et al. Cause or effect? Selective serotonin reuptake inhibitors and falls in older adults: a systematic review. Am J Geriatr Psychiatry. 2015;23:1016-1028.